Sculptra and Insurance

Apr 3, 2006

My federal Blue Cross/Blue Shield plan brochure lists (under "reconstructive surgery) cosmetic surgery as "not covered". It defines cosmetic surgery as "any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form - unless required for a congenital abnormality or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)". It would seem that Sculptra should be covered for lipoatrophy due to HIV disease. BC/BS refuses to give me an answer over the phone. They suggest I have the surgeon submit precertification request, but won't even guarantee payment for that visit although he's part of my PPO. It sounds like a catch 22. What would you suggest for a course of action? Thanks

Response from Ms. Franzoi

This is a difficult question. Most health plans consider Scultra, Restylane, etc. as cosmetic procedures, even if one has lipodystrophy, and therefore do not cover it. However, under
California Health and Safety Code Section 1367.63, there is a requirement to cover reconstructive surgery but it does not require coverage for cosmetic surgery. If the health plan is self-insured rather than insured, it is not subject to this state law. Although other states might have similar laws, I am not aware of which have or do not have such laws. Since this is a grey area, BC/BS probably cannot tell you without the doctor's evaluation whether or not the procedure would be covered for you. Your best option would be to go for the consultation.

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